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Exhibit A <br /> Sample Claim Certificate <br /> [Insert date] <br /> [Insert Trustee's name pursuant to trust agreement's preamble] <br /> [Insert Trustee's address pursuant to Section 19(b) of trust agreement] <br /> Daniela Golden <br /> Region 8 CERCLA Financial Analyst <br /> CERCLA Technical Enforcement Program <br /> Mail Code: 8ENF-RC <br /> 1595 Wynkoop Street <br /> Denver, Colorado 80202-1129 <br /> (303) 312-6772 <br /> Golden.daniela@epa.gov <br /> Re: Request for payment from the Trust [insert trust account number] established as <br /> financial assurance for the Camp Bird Mine Site <br /> Dear [insert name of Trustee and Ms. Golden]: <br /> Pursuant to Section 4 of the subject trust,the Grantor(as defined therein) and/or its <br /> representatives or contractors are authorized to request that the Trustee (as defined therein)make <br /> payment from the trust for Work(as defined therein)performed under the Settlement(as defined <br /> therein)by delivering to the Trustee (as defined therein) and the EPA(as defined therein) a <br /> written request for payment signed by an officer of the requesting entity. By this letter, Caldera <br /> Mineral Resources, LLC,requests payment from the trust. The bases for the payment request are <br /> more fully described below. <br /> 1. Certification: [insert certification from officer of requesting entity that the <br /> request is submitted for Work performed in accordance with the Settlement]. <br /> 2. Description of Applicable Work: [insert description of the Work that has been <br /> performed]. <br /> 3. Amount of Payment Request: [insert amount of funds requested from trust]. <br /> 4. Proposed Payee: [insert identification of payee(s) of the funds requested]. <br /> Please let me know if you have any questions. I can be reached at [insert telephone <br /> number and email address]. <br /> Sincerely, <br /> [insert name of officer of the requesting entity] <br /> [insert address of the requesting entity] <br /> A-1 <br />